HESI LPN
HESI Fundamentals Exam
1. A client with a history of diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the nurse to take?
- A. Monitor the client's blood glucose level.
- B. Encourage the client to increase fluid intake.
- C. Administer insulin as prescribed.
- D. Assess the client's urine output.
Correct answer: A
Rationale: The most critical action for the nurse to take when a client with diabetes mellitus presents with symptoms of hyperglycemia such as polyuria, polydipsia, and polyphagia is to monitor the client's blood glucose level. This action helps in assessing the client's current glycemic status and guides further interventions. Encouraging increased fluid intake (Choice B) may be beneficial in managing dehydration caused by polyuria, but it does not address the underlying cause of hyperglycemia. Administering insulin as prescribed (Choice C) may be necessary based on the blood glucose monitoring results, but monitoring should precede any medication administration. Assessing the client's urine output (Choice D) is important but does not directly address the primary concern of evaluating and managing hyperglycemia in a client with diabetes.
2. A client with a history of heart failure presents to the clinic with a 2-day history of weight gain, swelling in the legs, and shortness of breath. Which of the following is the most appropriate initial nursing action?
- A. Perform a physical assessment
- B. Review the client's medication list
- C. Instruct the client to elevate the legs
- D. Obtain a detailed dietary history
Correct answer: A
Rationale: Performing a physical assessment is the most appropriate initial nursing action in this scenario. A thorough physical assessment helps evaluate the client's current condition, severity of symptoms, and identify any immediate concerns. This assessment can provide crucial information to guide further interventions and treatment. Reviewing the client's medication list (choice B) is important but may not address the immediate need for assessing the client's current status. Instructing the client to elevate the legs (choice C) may be beneficial but should come after a thorough assessment. Obtaining a detailed dietary history (choice D) is relevant for heart failure management but is not the most urgent initial action when the client presents with acute symptoms like weight gain, leg swelling, and shortness of breath.
3. A nurse is preparing to administer methylprednisolone 10 mg by IV bolus. The amount available is methylprednisolone injection 40-mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Do not use a trailing zero.)
- A. 0.3 mL
- B. 0.25 mL
- C. 0.4 mL
- D. 0.5 mL
Correct answer: A
Rationale: To calculate the mL to administer, use the formula: Dose required (mg) ÷ Stock concentration (mg/mL) = Volume to administer (mL). In this case, 10 mg ÷ 40 mg/mL = 0.25 mL. However, when rounding to the nearest tenth, the answer should be 0.3 mL. Therefore, the nurse should administer 0.3 mL. Choice A is the correct answer. Choice B (0.25 mL) is the result obtained before rounding. Choice C (0.4 mL) and Choice D (0.5 mL) are incorrect calculations.
4. If a security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses, which statement by a nurse indicates understanding?
- A. “I will get the caller off the phone as soon as possible so I can alert the staff.”
- B. “I will begin evacuating clients using the elevators.”
- C. “I will not ask any questions and just let the caller talk.”
- D. “I will listen for background noises.”
Correct answer: D
Rationale: The correct answer is D: “I will listen for background noises.” Listening for background noises can provide useful information about the bomb’s location, helping security to assess the situation more effectively. Choice A is incorrect because disconnecting the call abruptly may prevent gathering important details. Choice B is incorrect as using elevators during a bomb threat can be dangerous; it is safer to use stairs for evacuation. Choice C is incorrect because actively engaging with the caller to gather information is crucial in bomb threat situations.
5. A client with a history of asthma is experiencing shortness of breath. What is the most appropriate action for the LPN/LVN to take first?
- A. Administer a bronchodilator as prescribed.
- B. Encourage the client to practice deep breathing exercises.
- C. Position the client in high Fowler's position.
- D. Obtain a peak flow reading.
Correct answer: A
Rationale: Administering a bronchodilator as prescribed is the most appropriate initial action for managing asthma-related shortness of breath. Bronchodilators help to open up the airways quickly, providing relief for the client. Encouraging deep breathing exercises may be beneficial in some situations but should not be the first action for acute shortness of breath in asthma. Positioning the client in high Fowler's position can also help improve breathing, but administering the bronchodilator takes precedence. Obtaining a peak flow reading is important in asthma management, but it is not the initial action needed to address acute shortness of breath.
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